New ESGE Recommendations for Management of Polyposis Syndromes

Douglas K. Rex, MD, FASGE reviewing van Leerdam ME, et al. Endoscopy 2019 July 23.

This is a comprehensive document from the European Society of Gastrointestinal Endoscopy. Following are some of the key recommendations:

For familial adenomatous polyposis (FAP)/MUTYH-associated polyposis

• Polyposis syndromes should be managed in dedicated units.
• Start colonoscopy in FAP at 12 to 14 years of age and in MUTYH at 18 years, with 1- to 2-year intervals for both.
• Timing and type of surgery in FAP and MUTYH should consider sex (fertility), polyp burden, rectal involvement, desmoids in patient and family, and mutation site.
• After colectomy, intervals for the rectum or pouch should be 1 to 2 years.
• All lesions pre- and post-colectomy >5 mm should be resected.
• Start duodenal surveillance in FAP at 25 years of age, and resect all lesions ≥10 mm in FAP/MUTYH. 

For serrated polyposis syndrome (SPS)

• Remove all lesions ≥5 mm.
• One-year intervals are recommended if there is ≥1 advanced polyp (advanced adenoma or sessile serrated polyps ≥10 mm or with cytological dysplasia) or ≥5 nonadvanced, clinically relevant polyps (any polyp that is not advanced and not a hyperplastic polyp <5 mm); otherwise 2-year intervals are recommended.
• Screen first-degree relatives by colonoscopy every 5 years starting at 45 years of age.

There are also detailed recommendations for Peutz-Jeghers syndrome and juvenile polyposis syndrome.

COMMENT

The evidence base to support most of the recommendations is low quality. In my own practice, I tend to remove all the adenomas in FAP patients by cold snaring pre-colectomy (if we intend to delay colectomy) and post-colectomy and count the total number of lesions and those ≥10 mm. The goal is to lower the number of polyps removed in successive examinations, with shortening of the interval if lesion numbers go up in successive examinations. In SPS, I tend to expand to 2-year intervals when there are still slightly greater polyp burdens than described here, but this is only after detailed clearing of the whole colon, usually with Endocuff.